A warning has been made over the possible side effects of a common NHS antibiotic by a coroner after a newly retired senior doctor died by suicide.
"Respected and experienced" consultant cardiologist Robert Stevenson had no history of depression or mental health problems before he started a course of ciprofloxacin.
But just over a week later, the 63-year-old went for a walk and messaged his wife to tell her he had left a note under his pillow.
He was later found dead in a nearby wood.
The note he had left was said to be "uncharacteristically confused and illogical" with "baseless concerns" that he might have AIDS after taking an online HIV tester kit, an inquest heard.
The hearing was told Dr Stevenson hadn't been told about a "potential rare link" to suicidal behaviour in patients who took the drug, as this wasn't in line with medical guidance.
Now, West Yorkshire coroner Martin Fleming issued a warning to highlight the risk of taking the antibiotic, which is prescribed by the health service for serious conditions.
The Prevention of Future Deaths Report said Dr Stevenson, a Consultant Cardiologist and General Physician at Huddersfield Royal Infirmary, had retired in May 2022.
At that time, he had been referred to a urology department for the investigation of possible prostate cancer, with a private consultant urologist.
To help with the inflammation of his prostate gland and to get him ready for an investigative biopsy, he was prescribed ciprofloxacin, an antibiotic used to treat a number of bacterial infections.
Just over a week later, Mr Stevenson left his home for his "usual walk".
According to the report, "he had not previously given any indications to his family for them to be concerned for him".
But that afternoon at 12.30pm, his wife received a Facebook message from him saying he had left a note under the pillow of his bed.
"The note was found to be uncharacteristically confused and illogical given his reference to his baseless concerns that he may have developed AIDs after taking an HIV tester kit he had previously bought online," the coroner said.
"Concerns were raised for his welfare, and this triggered an intensive police and family search of the surrounding area."
Mr Fleming concluded: "Robert Stevenson intended to take his own life when the balance of his mind was disturbed."
Writing to the Medicines & Healthcare products Regulatory Agency (MHRA), the coroner said that doctors may not be aware of the potential side effect.
"During the inquest, I was referred by Mr Stevenson's treating urologist to published literature relating to Ciprofloxacin and Quinolone antibiotics and a potential rare link to suicide behaviour in patients.
"Although I found on the balance of probabilities that it remained unclear that he was suffering from this side effect, it remained possible for this to be the case.
"I heard evidence to suggest that the prescribing doctor did not reference this side effect at the time of issuing the prescription to Mr Stevenson, since it was not in accord with current advice.
"I also heard evidence to suggest that prescribing doctors may not be fully aware of this rare side effect and that patients suffering from depression may be more vulnerable to it.
"I am therefore concerned that this potential risk has not been given sufficient emphasis.
"I would ask you to consider the appropriateness of reviewing the current guidelines as to the dispensation of the drug to patients by clinicians and increasing the awareness of the side effect in order to monitor and mitigate the risks."
The MHRA have until August 1 to respond.
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